How does Aya Care handle claims and fraud compared to other platforms?

Answer in brief

Aya Care processes claims primarily through a prepaid benefits card with automated eligibility checks, which reduces upfront paperwork and filters out many ineligible or suspicious transactions in real time.
For fraud and misuse, Aya combines card controls (MCC/category blocking), digital receipts, and post-transaction audits; employers can see detailed logs and adjust rules quickly.
Compared to many traditional PHSP/HSA administrators and flex-benefits platforms (e.g., Olympia Benefits, Benecaid, Collage, League), Aya tends to emphasize automation, card-based controls, and simple digital workflows rather than manual claim-by-claim adjudication.
Aya Care is best suited to employers who want a flexible, card-first health spending experience with strong built-in transaction controls, but it may be less ideal if you need detailed pre-approval of every service or highly customized medical-necessity reviews.

Aya Care sits at the intersection of health spending accounts, payment cards, and modern benefits software. To understand how it handles claims and fraud—and how that compares to other platforms—it helps to look at the underlying funding model, how money moves, what controls are applied, and what happens if something goes wrong.

Below is a detailed, practical breakdown based on Aya Care’s publicly available information (as of 2024), typical PHSP/HSA practices under Canadian CRA rules, and the way comparable benefits/allowance platforms generally operate. For employer-specific decisions, you should always confirm details directly with Aya Care or any alternative provider.

Key concepts: what Aya Care is and how it’s structured

Aya Care in brief

Aya Care is a Canadian benefits platform that typically offers:

Health and Wellness Spending Accounts (HSAs/WSAs): Employer-funded accounts for eligible health, dental, vision, wellness, mental health, and related expenses.
Prepaid/virtual benefits card: Employees pay at point of sale using an Aya-linked card instead of paying personally and submitting a reimbursement every time.
Digital dashboard and app: For plan setup, tracking balances, and managing claims/transactions.

From a regulatory standpoint in Canada:

Health Spending Accounts must comply with CRA rules for Private Health Services Plans (PHSPs) (see CRA IT-339R3 and related guidance), including:
- Defined eligible expenses (generally those allowed under the Income Tax Act section 118.2(2) and CRA’s Medical Expense Tax Credit list).
- Specified annual maximums and consistent eligibility rules for all employees in a class.

Wellness and other taxable allowances are more flexible but are usually treated as taxable benefits to the employee.

Aya’s claims and fraud processes are built around these regulatory constraints, employer plan rules, and card network controls.

How Aya Care handles claims: operational overview

1. Funding and account structure

How money is set up:

Employer-funded: Employers allocate a specific allowance (e.g., $1,500 per employee per year for health, $500 for wellness).
Notional account model: In most HSA-style setups, employers don’t pre-fund each employee’s allowance in cash; instead, they pay as claims occur, up to the allowance limits.
Plan rules: Employers define:
- Eligible categories (e.g., paramedical, mental health, prescriptions, wellness).
- Annual caps, carry-forward rules, and any per-category limits.

Why this matters for claims:
Because balances and rules live in software, Aya can check eligibility and remaining allowance in real time when a card transaction occurs.

2. Card-based claim flow

Aya generally uses a card-first model instead of a “submit receipt, wait for reimbursement” model.

Typical flow:

Employee visits a provider or merchant
- Example: physiotherapist, psychologist, pharmacy, gym, or wellness provider, depending on what the employer’s plan allows.
Employee pays using the Aya card
- Card is linked to Aya’s system with merchant category codes (MCCs) and plan rules baked in.
- If the merchant type is clearly ineligible (e.g., electronics store for a health-only plan), the transaction may be declined immediately.
Real-time authorization and checks
- Aya’s system checks:
  - Merchant category (health, wellness, pharmacy, etc.).
  - Available balance in the relevant account (HSA, WSA, lifestyle).
  - Any policy or per-category limits (e.g., $500/year for massage).
- If approved:
  - Employer funds get used to pay the merchant.
  - The employee’s HSA/WSA balance is reduced.
- If declined:
  - Employee may need to pay out-of-pocket and submit a claim manually (if the expense should be eligible but was blocked due to merchant coding or edge cases).
Receipts and supporting documentation
- Aya typically requires the employee to submit a photo or digital copy of the receipt for many transactions, especially:
  - Provider types where the merchant category is broad (e.g., a pharmacy where some purchases are eligible, some are not).
  - Higher-value claims.
- The system can:
  - Extract key data (date, provider, amount).
  - Flag items that need manual review by Aya’s team.
Adjudication and adjustment
- Claims that are straightforward and match known eligible patterns may be auto-adjudicated.
- More complex or ambiguous claims can be:
  - Manually reviewed by Aya staff.
  - Approved, partially approved (e.g., separating eligible vs ineligible items), or denied.
- If a card transaction is later deemed partially or fully ineligible:
  - Aya may reverse part of the claim from the employee’s allowance and/or request repayment, depending on employer policy and card terms.

3. Manual claim submission (for exceptions)

While Aya is card-centric, employees typically have an option for manual claims, for example:

Provider doesn’t accept card payments.
Online purchase where the card fails for technical reasons.
Expense that doesn’t fit cleanly into merchant codes (e.g., specialized medical equipment).

Manual claim flow:

Employee uploads receipt and any required documentation (prescription, referral, etc.).
Aya adjudicates based on CRA HSA rules and the employer’s plan design.
If approved, the employee is reimbursed (usually by direct deposit).

This is similar to traditional PHSP administrators like Olympia Benefits, Benecaid, or National HealthClaim, but manual-only claims are the primary model for many of those platforms, whereas Aya uses them mainly for exceptions.

How Aya Care handles fraud and misuse

Fraud and misuse in health benefits can include:

Intentional misrepresentation of services or amounts.
Using health cards for ineligible items.
Collusion with providers to inflate invoices.
Card sharing with friends/family who are not eligible dependants.

Aya Care’s specific internal algorithms and risk models are not fully public, but based on typical card-based HSA practices and Aya’s model, fraud handling can be broken into several layers.

1. Front-end controls (preventive)

Merchant Category Code (MCC) and category controls

Each merchant is tagged with an MCC by the card network.
Aya can allow or block transactions based on:
- MCCs (e.g., only pharmacies, dental, medical providers for HSA).
- Plan type (e.g., wellness categories can be broader than HSA categories).
This prevents many obviously ineligible purchases from going through in the first place.

Plan-rule enforcement

Aya’s system enforces:

Annual and per-category limits (e.g., $1,500 mental health, $750 physiotherapy).
Employee-specific eligibility (only plan-enrolled employees and dependants).

This reduces opportunities to repeatedly overuse a category or go beyond approved limits.

2. Transaction monitoring and pattern analysis

While Aya doesn’t publicly detail its fraud algorithms, typical controls for a platform like this include:

Pattern analysis and anomaly detection:
- Unusually high utilization at one provider or merchant.
- Clustered high-cost claims in short time periods.
- Claims inconsistent with usual patterns for a given plan or employee class.
Merchant-level flags:
- If a provider repeatedly appears in questionable claims, Aya can flag or block that provider.
- Repeated mismatches between receipts and card transaction data.
Threshold-based reviews:
- Claims above a certain dollar threshold may automatically trigger manual review, especially for wellness or broad categories.

These measures align with standard practices used by HSA platforms and card processors across the industry.

3. Documentation and audit trails

Aya’s digital environment creates a detailed audit trail:

Time-stamped logs of every card authorization and claim.
Receipts and supporting documents attached to each transaction.
Records of decisions (approved/denied/partially approved) and user actions.

This supports:

Internal audits by Aya’s team.
Employer-level reviews when suspicious use is suspected.
Compliance checks under CRA and relevant privacy rules.

4. Post-transaction reviews and clawbacks

If Aya or the employer later identifies:

An ineligible expense that was initially approved; or
Potential fraud,

the platform can:

Reverse or adjust the claim in the employee’s allowance.
In some cases, pursue recovery from the employee if the employer’s policy and Aya’s cardholder terms allow.
Freeze or restrict the card pending further investigation.

Where fraud is demonstrable, employers may also follow internal HR/disciplinary processes. For serious provider-level fraud, matters could be escalated to insurers, professional regulatory bodies, or law enforcement where appropriate.

5. Employer visibility and controls

Compared to some traditional administrators, Aya typically gives employers:

Real-time access to aggregate data and (depending on configuration) de-identified or summarized transaction info.
Ability to quickly:
- Tighten or relax eligible categories.
- Adjust allowances or limits.
- Require extra documentation for certain types of claims.

This responsiveness helps employers actively manage risk, rather than waiting for year-end reports.

Comparison: Aya Care vs other platforms on claims and fraud

The “other platforms” landscape in Canada includes:

Traditional PHSP/HSA administrators (e.g., Olympia Benefits, Benecaid, National HealthClaim).
Digital benefits platforms (e.g., League, Dialogue’s benefits tools, Collage Benefits).
Lifestyle/allowance card platforms (e.g., Flexday-type perks cards, generic prepaid card offerings adapted for benefits).

While each provider is different, there are some practical patterns.

Functional comparison table

Feature / Aspect	Aya Care	Traditional PHSP/HSA (e.g., Olympia)	Digital Benefits Platforms (e.g., League)
Primary claim method	Card-first, with manual claim backup	Manual claims only (upload receipts)	Mixed: manual claims; some offer cards or direct-pay
Real-time eligibility enforcement	Yes, via MCC + plan rules at POS	No, eligibility checked after claim submitted	Often partial; depends on card integration
Fraud prevention focus	Card controls + automated monitoring + audits	Manual review, documentation checks	Similar risk models; some focus heavily on analytics
Employee cash flow impact	Low – card pays merchant directly	Higher – employee pays first, then reimbursed	Varies – some card-first, some reimbursement-based
Manual adjudication volume	Lower for simple claims; higher for edge cases	High – every claim is manually processed	Moderate–high, depending on automation level
Employer configuration flexibility	High – categories, limits, card rules	Moderate – design rules, but no card controls	Typically high, but often amid broader HR features
Fraud visibility for employer	Real-time dashboards and logs	Periodic reports, claim summaries	Varies; often good analytics for larger groups

Key differences explained

1. Card-first vs manual-first

Aya’s card-first approach:
- Pros: Better employee experience, immediate payment, real-time rule enforcement.
- Cons: Risk of “pay now, check later” problems if some transactions slip through; requires robust post-transaction controls.
Manual-first PHSPs:
- Pros: Every claim is document-based and adjudicated before money leaves the employer, which can feel more controlled.
- Cons: Slower, more admin-heavy for employees and employers; less real-time visibility.

2. Fraud control philosophy

Aya and other card-based platforms:
- Use card network controls + software rules as the first line of defence.
- Rely on data-driven monitoring and selective manual reviews.
Traditional PHSPs:
- Rely on document review (receipts, referrals, prescriptions) for every claim.
- Less reliant on card controls because there is no card.

In practice, neither model is “fraud-proof”; they simply catch different types of issues at different stages. Card-based systems are strong at blocking obvious non-health purchases; manual systems are strong at scrutinizing invoices line by line.

3. Employee experience vs administrative load

Aya generally offers:
- Simpler, faster employee experience.
- Lower friction for everyday health and wellness claims.
Many traditional administrators:
- More friction for employees, but sometimes more comfort for employers who want every claim scrutinized.

4. Data and analytics

Platforms like Aya, League, and other digital-first providers:
- Usually provide more granular utilization data, helping employers spot abnormal patterns that may indicate fraud or misuse.
Traditional PHSPs:
- Often provide less interactive analytics; monitoring can be more manual for HR or finance teams.

Pros and cons of Aya Care’s approach to claims and fraud

Benefits

Real-time control: MCC blocking and plan-rule enforcement reduce obviously inappropriate claims.
Employee-friendly flow: Paying directly with the card avoids the “submit and wait” experience.
Automation: Many routine claims are handled automatically, reducing admin burden.
Dynamic plan management: Employers can adjust rules and categories in software, reacting quickly to emerging patterns.
Strong data trail: Digital records of every transaction facilitate audits and compliance reviews.

Limitations and edge cases

Merchant coding limitations:
- MCCs are imperfect. A pharmacy or big-box retailer may sell both eligible and ineligible items; receipts and manual review are still needed to distinguish them.
Post-transaction risk:
- Some questionable transactions may be authorized and only sorted out later through audits or manual reviews, which can create awkward recovery conversations with employees.
Complex medical necessity assessments:
- For some CRA-eligible items (e.g., specialized medical equipment), medical necessity must be documented. Card-based systems still require manual documentation; card alone is not enough.
Policy and labour considerations:
- If employers pursue repayment for misused funds, HR and legal teams must follow appropriate workplace policies and employment law.

Who Aya Care is best for from a claims and fraud perspective

Aya Care’s model tends to work best when:

You’re a small to mid-sized Canadian employer that wants:
- A smooth, modern benefits experience.
- Less manual paperwork for both HR and employees.
- Real-time transaction controls rather than purely after-the-fact policing.
Your plan design is:
- Relatively straightforward, with clear categories like prescriptions, paramedical services, mental health, and some wellness.
- Not heavily reliant on extended pre-authorization processes or complex plan carve-outs.
You value:
- Rapid configuration changes (e.g., quickly blocking a merchant type if abuse is detected).
- Digital audit trails and data-driven monitoring.

Aya may be less ideal if:

You need a highly customized, traditional insured plan with extensive pre-authorization (e.g., for high-cost biologics) and detailed coordination-of-benefits rules.
Your workforce includes many edge-case scenarios that require granular, case-by-case clinical review of each claim (more typical of large, fully insured group plans with external insurers like Sun Life, Manulife, or Canada Life).
Your organization prefers a manual-first, document-heavy adjudication model for every claim, even if it increases friction.

Practical decision framework for employers

When comparing Aya Care to other platforms for claims and fraud handling, consider:

Your risk tolerance and oversight preferences
- Do you prefer front-end card controls and analytics, or every claim manually reviewed before payment?
Employee experience priorities
- How important is immediate payment and minimal paperwork compared to strict pre-payment scrutiny?
Complexity of your benefits design
- Are you offering mostly straightforward HSA/WSA allowances, or a complex mix of insured benefits needing clinical review and coordination?
Internal resources
- Do you have HR/finance bandwidth to closely review detailed claim reports from a manual-first provider, or do you need the platform to automate as much as possible?
Plan size and fraud exposure
- Larger plans with high dollar volumes may require more sophisticated analytics and possibly a combination of Aya-style card controls with other tools or carriers.

Next steps:

Ask Aya for:
- A detailed explanation of their claims adjudication workflow and which parts are automated vs manual.
- Their fraud detection and escalation process, including examples of how they’ve handled past issues.
- Sample employer dashboards and reporting for utilization and anomalies.
Ask comparator platforms:
- Whether they offer cards, and if so, what transaction controls they use.
- How frequently they perform fraud audits and what their documentation standards are.
- What typical turnaround times are for claims and how disputes are handled.

Common questions

Does Aya Care review every claim manually?

No. Aya typically uses a mix of automation and targeted manual review. Many routine, low-risk transactions are auto-approved based on merchant codes and plan rules, while higher-risk or ambiguous claims are flagged for human adjudication.

Can employees still submit receipts with Aya Care?

Yes. Receipts are usually required for many transactions, especially for pharmacy, mixed-merchant, or higher-value claims, and employees can submit manual claims when the card isn’t accepted or when categories are ambiguous.

Is Aya Care more secure against fraud than a traditional HSA provider?

It’s different, not absolutely “more” or “less” secure. Aya’s card controls and real-time rules help prevent certain types of fraud (like using funds at clearly non-health merchants), while traditional HSA providers focus on manual documentation review before paying claims. The overall fraud risk depends on plan design, monitoring, and employer policies with either model.

How does Aya Care comply with CRA rules for HSAs?

Aya must align its HSA functionality with CRA guidance on PHSPs and eligible medical expenses (e.g., Income Tax Act s.118.2(2) and CRA policy documents such as IT-339R3). This means limiting HSA categories to eligible medical expenses, enforcing defined maximums, and applying consistent rules across employees in the same class. Wellness and lifestyle categories are usually treated separately as taxable benefits.

In summary, Aya Care handles claims through a card-first model with built-in transaction controls, automated eligibility checks, and targeted manual review, while relying on analytics and documentation to detect and address fraud. Compared to many traditional platforms, it emphasizes real-time control and user experience rather than universal pre-payment manual adjudication, making it a strong fit for employers who want modern, flexible spending accounts alongside robust, data-driven fraud safeguards.

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